Nursing of Adults with Medical & Surgical Conditions Endocrine Disorders

Acromegaly Etiology/Pathophysiology Overproduction of growth hormone in the adult Idiopathic hyperplasia of the anterior pituitary gland No known cause Tumor growth in the anterior pituitary gland Changes are irreversible

Acromegaly Signs & Symptoms Enlargement of the cranium and lower jaw Separation and malocclusion of the teeth Bulging forehead Bulbous nose Thick lips Enlarged tongue Generalized coarsening of the facial features Enlarged hands and feet Enlarged heart, liver, and spleen

Acromegaly Muscle weakness Hypertrophy of the joints with pain and stiffness Males – impotence Females – deepened voice, increased facial hair, amenorrhea Partial or complete blindness with pressure on the optic nerve due to tumor Severe headaches

Acromegaly Treatment Medications Cryosurgery Parlodel Sandostatin Inhibit production of growth hormone Cryosurgery Destroy tissue by freezing Transphenoidal removal of tissue Proton beam therapy Low doses of radiation Soft easy to chew diet Analgesics

Giantism Etiology/Pathophysiology Overproduction of growth hormone Caused by hyperplasia of the anterior pituitary gland Occurs in a child before closure of the epiphyses Other causes Genetic disorders Disturbances in sex hormone production

Giantism Signs & Symptoms Great height Increased muscle and visceral development Increased weight Normal body proportions Weakness

Giantism Treatment Surgical removal of tumor Irradiation of the anterior pituitary gland Requires replacement of pituitary hormones

Dwarfism Etiology/Pathophysiology Deficiency in growth homone Usually idiopathic

Dwarfism Signs & Symptoms Abnormally short height Normal body proportion Appear younger than age Dental problems due to underdeveloped jaws Delayed sexual development

Dwarfism Treatment Growth hormone injections Removal of tumor if present

Diabetes Insipidus Etiology/Pathophysiology Transient or permanent metabolic disorder of the posterior pituitary Deficiency of antidiuretic hormone Primary Secondary Head injury; intracranial tumor, aneurysm, or infarct; encephalitis or meningitis

Diabetes Insipidus Signs & Symptoms Polyuria Polydipsia Urine very dilute May exceed 10 L in 24 hours Polydipsia Craves cold water Up to 40 L of fluid daily May become severly dehydrated Lethergic Dry skin Poor skin tugor Constipation

Diabetes Insipidus Treatment ADH preparations Vasopressin IV, SQ, nasal spray Limit caffeine due to diuretic properties

Graves’ Disease Etiology/Pathophysiology Overproduction of the thyroid hormones Exaggeration of metabolic processes Exact cause unknown Risk factors Physical or emotional stress Pregnancy Adolescence Infection Genetic Autoimmune

Graves’ Disease Signs & Symptoms Edema of the anterior portion of the neck Enlargement of the thyroid Exphtalmos Bulging of the eyeballs due to periorbital edema Inablility to concentrate Memory loss Dysphagia Hoarsness Increased appetite Weight loss Nervousness

Graves’ Disease Insomnia Tachycardia Hypertension Warm, flushed skin Fine hair Amenorrhea Elevated temperature Diaphoresis Hand tremors

Graves’ Disease Treatment Medications Radioactive iodine Propylthiouracil Methimazole Block production of thyroid hormones Radioactive iodine Destroys part of thyroid tissue Subtotal thyroidectomy Part of thyroid is removed

Graves’ Disease Post-Op Voice rest Voice checks Avoid hyperextention of neck Tracheotomy tray at bedside Assess for s/s of internal and external bleeding High risk of hemorrhage Assess for tetany May occur due to accidental removal of parathyroid glands Decreases serum calcium levels Chvostek’s Sign Abnormal spasm of facial muscles elicited by light tap on the facial nerve Trousseau’s Sign Carpal spasm induced by inflation of B/P cuff on the upper arm for 3 minutes

Chvostek’s Sign

Trousseau’s Sign

Graves’ Disease Thyroid Crisis Caused by manipulation of thyroid Releases large amounts of thyroid hormones Usually occurs within first 12 hrs Exaggerated symptoms of hyperthyroidism Can be fatal if untreated

Hypothyroidism Etiology/Pathophysiology Insufficient secretion of thyroid hormones Slowing of all metabolic processes Failure of thyroid or insufficient secretion of TSH from pituitary gland Myxedema Adults Cretinism Newborns; congenital

Hypothyroidism Signs & Symptoms Depends on degree of thyroid hormone deficiency Hypothermia Intolerance to cold Weight gain Depression Impaired memory Slow thought process Lethargic Anorexia Constipation

Hypothyroidism Decreased libido Menstrual irregularities Thin hair Skin thick and dry Enlarged facial appearance Low hoarse voice Bradycardia Hypotension

Hypothyroidism Treatment Medications Symptomatic treatment Synthroid Levothyroid Proloid Cytomel Symptomatic treatment

Simple Goiter Etiology/Pathophysiology Enlarged thyroid due to low iodine levels Enlargement is caused by the accumulation of colloid in the thyroid follicles Usually cause by insufficient dietary intake of iodine

Simple Goiter Signs & Symptoms Enlargement of the thyroid gland Dysphagia Hoarseness Dyspnea

Simple Goiter Treatment Potassium iodide Diet high in iodine Surgery Thyroidectomy

Cancer of the Thyroid Etiology/Pathophysiology Malignancy of thyroid tissue Very rare

Cancer of the Thyroid Signs & Symptoms Firm, fixed, small, rounded mass or nodule of thyroid

Cancer of the Thyroid Treatment Total thyroidectomy Thyroid hormone replacement If metastasis is present: Radical neck dissection Radiation therapy, chemotherapy, and radioactive iodine

Hyperparathyroidism Etiology/Pathophysiology Overactivity of the parathyroid, with increased production of parthormone Hypertrophy of one or more of the parathyroid glands Usually due to an adenoma

Hyperparathyroidism Signs & Symptoms Hypercalcemia Skeletal pain Calcium leaves the bones and enters the bloodstream Skeletal pain Pain on weight bearing Pathological fractures Kidney stones Fatigue Drowsiness Nausea Anorexia

Hyperparathyroidism Treatment Removal of tumor Removal of one or more parathyroid glands

Hypoparthyroidism Etiology/Pathophysiology Decreased parathyroid hormone Decreased serum calcium levels Inadvertent removal or destruction or one or more gland during thyroidectomy

Hypoparthyroidism Signs & Symptoms Neuromuscular hyperexcitability Involuntary and uncontrollable muscle spasms Tetany Laryngeal spasms Stridor Cyanosis Parkinson-like syndrome Bizarre posturing Spastic movements Chvosteck’s sign &Trousseau’s sign

Hypoparthyroidism Treatment Calcium gluconate or calcium chloride IV Must be given very slowly due to irritation of vessel Rate should not exceed 1 ml/min Can precipitate cardiac arrest Vitamin D Increases absorption of calcium

Adrenal Hyperfunction Cushing’s Syndrome Etiology/Pathophysiology Plasma levels of adrenocortical hormones are increased Hyperplasia of adrenal tissue due to overstimulation by the pituitary gland Tumor of the adrenal cortex ACTH secreting tumor outside the pituitary Overuse of corticosteriod drugs

Adrenal Hyperfunction Cushing’s Syndrome Signs & Symptoms Moonface Buffalo hump Thin arms and legs Hypokalemia Proteinuria Increased urinary calcium excretion Susceptible to infections Depression Loss of libido

Cushing’s Syndrome

Adrenal Hyperfunction Cushing’s Syndrome Ecchymoses and petechiae Weight gain Abdominal enlargement Hirsutism in women Exessive hair in a masculine distribution Menstrual irregularities Deepening of the voice

Adrenal Hyperfunction Cushing’s Syndrome Treatment Treat causative factor Adrenalectomy for adrenal tumor Radiation or surgical removal for pituitary tumors Lysodren Cytotoxic agent to decrease production of adrenal steroids Low sodium, high potassium diet

Adrenal Hypofunction Addison’s Disease Etiology/Pathophysiology Adrenal glands do not secrete adequate amounts of glucocorticoids and mineralocorticoids May result from Adrenalectomy Pituitary hypofunction Long standing steroid therapy

Adrenal Hypofunction Addison’s Disease Signs & Symptoms Related to imbalances of hormones, nutrients, and electrolytes: Nausea Anorexia Postural hypotension Headache Disorientation Abdominal pain Lower back pain Anxiety

Adrenal Hypofunction Addison’s Disease Darkly pigmented skin and mucous membranes Weight loss Vomiting Diarrhea Hypoglycemia Hyponatremia Hyperkalemia

Adrenal Hypofunction Addison’s Disease Adrenal Crisis Sudden, severe drop in B/P Nausea & vomiting Extremely high temperature Cyanosis Death

Adrenal Hypofunction Addison’s Disease Treatment Restore fluid and electrolyte balance Replacement of adrenal hormones Florinef Diet high in sodium and low in potassium Adrenal Crisis IV corticosteroids in a solution of saline and glucose

Diabetes Mellitus Type I and Type II Etiology/Pathophysiology Unknown Risk Factors Heredity Blood relatives of people who have DM (esp Type II) are more likely to develop DM Environment and lifestyle Overweight, sedentary lifestyle are more prone to Type I DM Viruses Chickenpox-type viruses have been associated with the development of Type I DM Malignancy or Surgery of Pancreas Decreased functioning ability

Diabetes Mellitus Type I and Type II Pathophysiology Insulin deficiency May be decreased or none Insulin is secreted by the beta cells in the islets of Langerhans Insulin is necessary for the cells to combine O2 and glucose to produce energy If insulin is not present or is reduced, glucose accumulates in the blood and is excreted in the urine The body then uses proteins and fat for energy which can cause acidosis

Diabetes Mellitus Type I and Type II Classifications Type I Insulin Dependent (IDDM) Type II Non-insulin Dependent (NIDDM) Signs & Symptoms Type I & Type II Polyuria Polydypsia Polyphagia

Diabetes Mellitus Type I and Type II Sudden onset Weight loss Hyperglycemia Under 40 years old Type II Slow onset May go undetected for years “3 P’s” are usually mild Untreated may have skin infections & arteriosclerotic conditions

Diabetes Mellitus Type I and Type II Diagnostic Tests Urine glucose and acetone Neither are normally in urine Glucose in urine means the blood glucose has exceeded the “renal threshold” Blood glucose Venipuncture or capillary Glucose is always present in the blood Amount can fluctuate according to how much and what type of foods have been eaten Normal values 70-110 mg/dl

Oral glucose tolerance test Fasting (NPO for at least 8 hours) Fasting blood sugar is drawn Glucose drink administered Blood drawn at 1 hr, 2 hrs, and 3 hrs after drink 1hr: elevated 2hr: essentially normal 3hr: within normal limits 2 hour post-parandial blood sugar Blood sugar drawn 2 hours after a normal meal Values should be within normal limits Glycohemoglobin Glucose in hemoglobin Elevation means that the patient’s blood sugar levels were consistantly high for 6-8 weeks previously Values Non-diabetic adult: 2.2-4.8% Good diabetic control: 2.5-5.9% Fair diabetic control: 6-8% Poor diabetic control above 8%

Treatment Diet The cornerstone of treatment Usually based on caloric needs (pt. size, activity, etc) Type II may be controlled by diet alone Type I diet is calculated and then the amount of insulin required to metabolize it is established ADA diet (American Diabetes Association) 7 Exchanges Free calories Vegetables Fruits Bread Meat Fats Milk Quantitative Diet Carbohydrates – 45-50% of calories Proteins – 10-20% of calories Fats – no more than 30% of calories Need 3 regular meals with snacks between meals and at bedtime to maintain constant glucose levels

Carbohydrate Counting Adults with Type 2 diabetes generally need to limit carbohydrates to no more than 45-60 grams per meal and 15-30 grams for a snack. Eat three meals a day with one to three snacks.  Try to eat around the same times every day. Avoid skipping meals. Follow the food guide pyramid.  Pay attention to carbohydrate choices.  Stay within your recommended serving ranges. Limit foods that are high in added sugars and fats.  If you do consume foods with added sugar, be sure to count them into your carbohydrate choices. Avoid drinking high sugar beverages such as regular sodas, fruit juices, lemonade and punch.  All of these can be substituted with diet, low calorie, low sugar or light alternatives.

These foods count as one (1) carbohydrate choice: 1 oz dinner roll 1 cup (8 oz) milk  1/2 cup beans 1 slice bread 1 cup (8 oz) soy milk  1/2 cup corn  1/2 cup cooked cereal 8 oz yogurt (no added sugar) 1/2 cup green peas  3/4 cup dry cereal (varies)  1 taco  3 oz baked potato  2 - 4" pancakes 1 slice thin crust pizza  1 cup winter squash 1/2 cup pasta or potato salad 1 cup bean or noodle soup 1/2 cup canned fruit   1/2 cup pasta 1 granola bar 1/4 cup dried fruit 1/3 cup rice 3 graham cracker squares 1 cup berries 1 - 6" tortilla 1/2 cup sugar free pudding  1/2 medium grapefruit  1 - 4" waffle 10-15 potato chips  3 prunes  3 cups popcorn 1/2 cup ice cream 12-15 cherries or grapes 4-5 crackers  1 - 3" cookie 1 small apple or orange 1 small muffin 1 Tbsp syrup, honey, or sugar 1 cup melon 15 pretzels 1/3-1/2 cup fruit juice 2 Tbsp raisins

These foods count as two (2) carbohydrate choices: 1 - 8 to 11 oz frozen dinner 1 hamburger with bun 1 - 2-oz English muffin 1 cup lasagna (3" x 4" piece) 1 - 2-oz hamburger or hotdog bun 1 cup macaroni and cheese 1 cup sweetened yogurt  1 slice thick crust pizza 1 - 7" meat burrito 1/2 large bag light popcorn 1 medium banana or pear 1 small bagel 1 cup chili 1 cup casserole

Insulin Classified by Action Classified by Type Regular Lente & NPH Fast acting Peek action 2-4 hours Duration 5-8 hours Lente & NPH Intermediate acting Peek action 4-12 hours Duration 18-24 hours Ultralente Long acting Peek action 12-18 hours Duration 28-36 hours Classified by Type Beef/Pork derived from the pancreas of a pig or cow Humulin/Novolin synthetic human insulin

Regular Insulin is the ONLY form that can be given IV! Should be administered at room temperature Should be discarded after open for 3 months Standardized Dose 100 units/ml (U100) Use ONLY insulin syringes Administer subcutaneous

Insulin Injection Sites Should be rotated to prevent scar tissue formation Insulin is not well absorbed in scar tissue Sites Lateral surface of the upper arms Abdomen just below the rib cage Buttocks Anterior surface of thighs

Sliding Scale Insulin is given according to blood glucose levels Regular insulin is only type that should be given to scale Scales will vary on different patients, physicians, etc. Sample Scale Blood Sugar Insulin 200-225 2 units 226-250 3 units 251-275 4 units 276-300 5 units above 300 Call MD

Alternate Methods of Insulin Administration Insulin Pump

Alternate Methods of Insulin Administration

Alternate Methods of Insulin Administration

Combined blood glucose monitoring and insulin dosing system

Oral hypoglycemic agents Stimulate islet cells to secrete more insulin Must have some production of insulin by pancreas Only for Type II DM NOT insulin Side Effects hypoglycemia Types Orinase short acting 6-12 hours Tolinase interm. acting 12-24 hours Diabinease long acting up to 60 hours

Hygiene Exercise Prevention more than treatment Decreased resistance to infection Wounds heal more slowly Proper care of feet Clean Nail care Proper fitting shoes No heating pads Do NOT trim nails - MD only Exercise Promotes movement of glucose into the cell by changing the cell permeability Lowers blood glucose Lowers insulin needs

Insulin Reaction Hypoglycemia May be due to a sudden drop to below normal or may be due to a sudden drop from extremely high to normal Pathophysiology Too little circulating glucose Cause Too much insulin OR not enough food

Signs and Symptoms Trembling Perspiration Irrritability Dizziness Muscle weakness Headache Blurred vision Hunger Confusion Comatose Convulsions

Treatment Increase blood glucose High calorie drink Orange juice Cola Concentrated sugar Candy Jelly Then complex foods Carbohydrates Proteins If unconsious 50% dextrose IV

Diabetic Acidosis/Ketoacidosis Hyperglycemia Usually occurs in Type I (IDDM) Cause Lack of insulin Accumulation of glucose and wastes from fat and protein metabolism

Signs & Symptoms Polyuria Polydipsia Polyphagia Nausea & vomiting Weakness Headache Flushed face Late Symptoms Sweet fruity breath Hypotension Tachycardia Kussmaul’s Respirations Loud, deep and rapid resp. followed by apnea BS may be as high as 1000mg/dl

Treatment Regular insulin IV Fluids and electrolyte replacement Find cause and educate patient

Chronic Complications Macrovascular changes Caused by atherosclerosis Intermittent claudication Stroke Gangrene Coronary artery disease Microvascular changes Caused by changes in the capillaries Eyes diabetic retinopathy cateracts Kidneys nephropathy Infection High BS levels cause poor circulation and decreased sensation CNS disturbances Metabolic imbalances affects the sensory and motor fibers

Other Complications Surgery Tests “Sick Days” Stresses the body Pts. who required no insulin, may now require insulin Pts. who were on insulin, will probably require increased doses Tests NPO Need to consider how long they will be NPO and what type insulin they are taking “Sick Days” Increased risk of ketoacidosis (hyperglycemia) Glucose must be monitored closely

Patient Education Diet Exercise Medications Hygiene Consider Intellect Motivation Physical ability (vision, etc) Social and personal resources Success depends on ability and willingness